The challenge of secondary alveolar reconstruction

The management of cleft lip and palate requires a critical surgical step: the reconstruction of the alveolar cleft. This structural defect, if left uncorrected, compromises the eruption of permanent canines, the stability of the dental arch, and the support of the nasal base. Although various bone substitute alternatives exist, autogenous harvesting from the iliac crest remains a preferred approach for many teams due to its cellularity and volume. However, the clinical challenge lies in the predictability of graft integration and its impact on the patients' aesthetic quality of life.

Study objective and hypotheses

This prospective observational study's primary objective is to evaluate the clinical and aesthetic outcomes of using iliac crest grafts for secondary alveolar reconstruction. Beyond simple bone survival, the authors seek to quantify success via the Bergland score at four months post-operatively and to measure the cosmetic satisfaction perceived by the patient. The study is based on the hypothesis that there is a significant correlation between the absence of immediate post-operative complications, the radiographic success of bone integration (Bergland score ≤ 3), and the overall satisfaction felt by the operated subject.

Study methodology

This prospective observational study was conducted within the department of oral and maxillofacial surgery at Saidu Teaching Hospital (Pakistan) over a period extending from September 2024 to April 2025. The objective was to evaluate the clinical and aesthetic outcomes of iliac crest bone grafting in the context of secondary alveolar reconstructions.

The study population consisted of 65 patients with cleft lip and/or palate. The sample characteristics included:

• A majority of male patients (84.6%, n=55).
• A predominance of cleft lip and palate (81.5%, n=53).
• A high proportion of unilateral cases (86.2%, n=56).

The experimental protocol consisted of performing an autologous bone graft harvested from the iliac crest. The analysis of the results was carried out according to two main parameters four months after the procedure:

• Radiographic evaluation: Use of the Bergland score, where reconstruction success was defined by a score ≤ 3 (observed mean of 2.01 ± 0.92).
• Satisfaction assessment: Collection of patients' cosmetic feedback categorized as "Satisfied", "Neutral" or "Dissatisfied".

Postoperative follow-up also included monitoring for complications (infection, resorption, dehiscence). Statistical correlations were analyzed to link graft success to patient satisfaction (p < 0.001).

Clinical performance and graft integration

Analysis of the results at four months post-operatively demonstrates high efficacy of the iliac crest graft for the reconstruction of secondary alveolar clefts. The success criterion, defined by a Bergland score of 3 or less, was achieved in 95% of the treated cases.

Statistical significance and clinical correlations

The study highlights a highly significant statistical association (p < 0.001) between the radiographic success of the graft and the complication profile. Relative failures (higher Bergland scores) are systematically linked to the occurrence of infectious episodes or early resorption.

Qualitatively, patient satisfaction with the aesthetic result was evaluated according to three categories: "Satisfied", "Neutral" and "Dissatisfied". The data reveal a strong correlation (p < 0.001) between the success of bone integration and the reported aesthetic satisfaction, confirming that the structural stability of the iliac graft directly determines the final cosmetic outcome.

• Functional integration: The majority of patients achieved a Bergland score of 1 or 2, indicating optimal bone filling of the cleft.
• Morbidity: Complications remain marginal, with absorption (7.7%) being the main limiting factor identified during the four-month follow-up.

Analysis of results and clinical relevance

The data from this prospective study confirm the robustness of the iliac graft for secondary alveolar reconstruction. With a success rate of 95% (defined by a Bergland score ≤ 3), the technique demonstrates high predictability for the restoration of arch integrity. Clinically, the mean Bergland score of 2.01 ± 0.92 reflects quality bone incorporation, essential for the support of adjacent dentition and potential implant placement.

The most salient aspect of this research is the close statistical correlation (p < 0.001) between the objective success of the graft and the patient's aesthetic satisfaction. This underlines that surgical success is not measured solely by imaging, but directly impacts the patient's psychosocial perception. The low complication rate (resorption at 7.7% and infection at 4.6%) favorably positions the iliac donor site despite its invasive nature compared to synthetic alternatives.

Limits and perspective

The study is limited by its observational nature and the absence of a control group comparing other donor sites (such as the mandibular symphysis or the cranial vault) or bone substitute materials. Furthermore, the follow-up focuses on four-month results, which, although sufficient to evaluate initial graft take, does not allow for the observation of long-term volumetric stability under orthodontic or implantology constraints.

Implications for practice

For the practitioner, these results validate the choice of the iliac crest as a first-line option for complex unilateral and bilateral clefts. Meticulous soft tissue management remains a top priority, as suture dehiscence, although rare (3.1%), is a direct risk factor for graft failure. Rigorous postoperative follow-up is essential for the early detection of signs of resorption or infection, thus ensuring the intended functional and aesthetic integration.

Summary of results

This prospective study confirms the efficacy of iliac crest grafting with a 95% success rate (Bergland score ≤ 3) and a mean score of 2.01 ± 0.92. Surgical complications remain limited, dominated by resorption (7.7%) and infection (4.6%), while patient aesthetic satisfaction is statistically correlated with the success of bone integration (p < 0.001).

In concrete terms, for the practitioner:

• Maintain the iliac crest as the reference: This autogenous source offers high predictability for the reconstruction of alveolar clefts, ensuring both functional integration and aesthetic satisfaction.
• Anticipate minor complications: Although the failure rate is low, remain vigilant regarding the risks of resorption and infection (approximately 12% of cumulative cases) through rigorous postoperative follow-up from the first months.
• Validate technical success for aesthetics: Since the success of the Bergland score is directly linked to patient satisfaction, the precision of graft positioning is the primary lever for perceived success.

Technical lexicon of the study

Secondary alveolar reconstruction: Surgical procedure aimed at filling the bony cleft of the dental arch, generally performed in mixed dentition to allow the eruption of adjacent teeth and stabilize the maxillary segments.

Iliac crest bone graft: Autogenous bone harvesting (often cancellous) from the hip bone, considered the gold standard for alveolar cleft reconstruction due to its high cellularity and osteogenic potential.

Bergland score: Radiographic grading system used to evaluate the success of alveolar bone grafting. In this study, a score less than or equal to 3 is defined as a reconstruction success.

Cleft lip and palate: Complex congenital malformation combining a division of the upper lip and a communication between the oral and nasal cavities through a division of the palate.

Resorption: Physiological or pathological process of bone graft volume loss during the remodeling phase, which can impact the final height of the interdental septum.

Suture dehiscence: Postoperative complication characterized by the separation of the surgical wound edges, increasing the risks of graft exposure and secondary infection.

Unilateral: Characterizes a cleft present on only one side of the maxillary arch, as opposed to bilateral forms.

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